TRANSFUSION SCIENCE


harm results or not”. The possible outcome for these near-miss incidents where the blood groups would have been incompatible are shown in Figure 1.


ICE: identification, communication, education Key SHOT messages • There is no substitute for correct patient identification at all stages in the transfusion process


• The severity of the outcome is not the determinant of the seriousness of the error. Near-miss reporting demonstrated 889 errors which could have resulted in incorrect blood component transfusions, of which 288 were known to be potentially ABO-incompatible


• Delay in appropriate transfusion contributes to death in sick patients


• Risk assessment before transfusion. Transfusion-associated circulatory overload (TACO) is the most common cause of death and of major morbidity and may be preventable. Patients should be assessed properly prior to transfusion to identify those at particular risk and to ensure the transfusion is required


• Information technology (IT) systems depend on correct set-up and validation to ensure they are fit for purpose and contribute to patient safety rather than impede it


• Errors in the administration of anti-D immunoglobulin remain disappointingly high; clear local guidelines and thorough training of all staff involved is essential


• Checking means checkingwith no short cuts


• Laboratory error reports to SHOT have increased and human error accounts for 96.7% of serious adverse events reported to the MHRA.


Key recommendations Be WARM: work accurately and reduce mistakes • A formal pre-transfusion risk assessment for transfusion-associated circulatory overload (TACO) should be performed whenever possible as TACO is the most commonly reported cause of death and major morbidity. An example is given in Chapter 13 (Pulmonary Complications) of the main report (Fig 2).


• Use a five-point practice improvement tool (checklist) at the patient’s side immediately prior to connection of the transfusion (Fig 3). Never do this away from the patient. Practice should be audited prior to introduction and regularly afterwards to demonstrate improved and safer practice.


Action: Trust/Health Board Chief Executive Officers and Medical Directors responsible for all clinical staff


• Additional new topic-related recommendations can be found in the following chapters: Chapter 11 (Acute Transfusion Reactions [ATR] [n=1]), Chapter 16 (Paediatric Summary [n=2]) and Chapter 26 (Cell Salvage [CS] [n=5]).


CONTACT DETAILS SHOT Office


Manchester Blood Centre Plymouth Grove Manchester M13 9LL Tel +44 (0) 161 423 4208 Fax +44 (0) 161 423 4395 Website www.shotuk.org Enquiries shot@nhsbt.nhs.uk


Steering Group Chair: Dr Dafydd Thomas


Medical Director and Working Expert Group Chair: Dr Paula Bolton-Maggs


Working Expert Group and Writing Group, on behalf of the SHOT Steering Group: Ms Alison Watt, Ms Debbi Poles, Mr Tony Davies, Mrs Hema Mistry, Mrs Julie Ball, Ms Claire Reynolds, Dr Su Brailsford, Dr Catherine Chapman, Mrs Alexandra Gray, Mrs Joan Jones, Mrs Clare Milkins, Dr Helen New, Dr Megan Rowley, Dr Fiona Regan, Dr Hazel Tinegate, Dr Janet Birchall, Mr Mike Dawe, Dr Peter Baker, Dr Jane Keidan, Dr Hannah Cohen, Dr Dafydd Thomas.


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